LTC Reviews

• Overview

Setup

Sending Invitations

Booking Appointments

Sending Reminders

The Tests

The Review

The Follow-Up

Exempting Patients



Ardens uses reports & months of birth for Long Term Condition (LTC) reviews. Watch the video below for an overview of the LTC Review process. 


Setting up the Ardens LTC Review process within a practice requires 3-4 months planning in order to complete the setup, train your staff and migrate to the new process. The online resources here should allow you to with this process but we also advise you to book some LTC Review training at your surgery for all your staff too.




LTC Review Conditions Included 

The following conditions are included in the reports for sending LTC review invitations. If you think further conditions should be included, please contact us. For conditions not included below, these should be reviewed during a routine annual medication review. For further information about what is included, please see here.      


BP + Pulse:    
HTN, AF
Cardiovascular:
CHD, CHF, PAD, CVA/TIA
Diabetes:
DM1, DM2, Pre-Diabetes, Gestational Diabetes
Renal:
CKD 1-5
Mental Health:
Bipolar, Dementia, Learning Disability, Psychosis
Respiratory:
Asthma (if bronchodilator issued in last year), COPD
Other:
RA, Coeliac Disease, Severe Frailty, Post-Bariatric Surgery


LTC Pre-Appointment Tests Included 

For a summary of the pre-appointment tests that are requested, please see here.


Sending Invitations Using Reports

Ardens use reports, not recalls, for sending invitations as reports are not reliant on users adding/superseding/removing recalls. They also do not require time maintaining if a new patient registers or a practice merges. Reports also ensure only a single invitation is sent to a patient with multiple co-morbidities.


Please note:

• A new patient must be reviewed at the time of registration. 

• A new diagnosis must be reviewed at the time of diagnosis. 

• Good data quality is required for new & resolved diagnoses (see here

• The system is reliant on a single read code Xaagy – Chronic disease management annual review completed being added after the annual review is completed. This is to ensure that 2nd or 3rd invites are not sent out. 

• Whilst invitations are only sent annually, some conditions require more frequent review. Additional reviews should be booked at the time of the previous appointment. 

• This is not an all-encompassing solution for every condition & circumstance. Clinical expertise and judgement is still required at all stages. It is the practice’s responsibility to check the reports/templates/alerts prior to commencing the LTC review process.


NEXT: Setup